General Practitioner Pathology - Laboratory Service Provision Policy Policy No: SJH: LabMed (P):003

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1 Page 1 of 6 St. James s Hospital LabMed Directorate General Practitioner Pathology - Laboratory Service Provision Policy Policy No: SJH: LabMed (P):003 Ownership: Laboratory Manager Approved by Laboratory Clinical Director Dr. Brian O Connell Reviewed by: Laboratory Quality Manager Effective from: January 2012 Revised: April 2016 Revision Due: April2018 Document History: Version 5 April 2016 This policy replaces all existing policies from April 2016 onwards and is due for review in April It will be reviewed during this time as necessary to reflect any changes in best practice, law, and substantial organisation, professional or academic change. Distributed to: Local Health Offices (LHO) in the Dublin region, SICP, DSW, Laboratory Personnel; Deputy CEO of St James s Hospital Posted SJH Intranet: Policy Statements The Laboratory Medicine (LabMed) Directorate of St James s Hospital is committed to the provision of an accredited service to General Practitioners (GPs) for patients within the St. James s Hospital catchment areas. It will pursue the optimisation of service infrastructure to enhance order communications for test ordering and reporting of results. GPs requiring access to pathology services for the purpose of occupational health screening are required to enter into a service level agreement with the SJH LabMed Directorate. GPs requiring access to pathology services for the purpose of treating patients outside the Hospital s catchment area are required to enter into a service level agreement with the SJH LabMed Directorate. The St. James s Hospital catchment areas for diagnostic laboratory and phlebotomy services can be accessed on the Hospital Internet at Policy Aims 2.1 To define the catchment areas within which St James s Hospital Laboratory will provide phlebotomy and laboratory services to General Practitioners 2.2 To direct General Practitioners using the laboratory services in the procedures and standards they are required to meet in order for the laboratory to provide a safe and effective quality service. These are outlined in the standards in Section 3 below

2 3.0 Standard Requirements from General Practitioners Page 2 of Provision of contact details for reporting of critical results outside normal practice hours All GP practitioners requiring laboratory medicine services must provide contact details for reporting of critical results outside normal practice hours. This is a mandatory requirement for access to the Hospital s laboratory services New General Practitioners requesting access to the Laboratory services in St. James s Hospital must complete an application form (available from the Quality Manager). Sections of the form require GPs to give the emergency contact number and to commit to using Healthlink or other communication portal agreed with St. James s Hospital for test requesting and receiving electronic reports Existing GPs must also provide this emergency mobile number as a mandatory part of retaining the contract for services. Where a proxy agency e.g. DubDoc is used by a GP Service, arrangements must be made between the relevant parties to ensure that markedly abnormal results can be telephoned directly to the agency, without complication. This is a critical clinical risk management issue for all parties concerned In the event that a proxy agency or the requesting GP is non contactable, then the Consultant Pathologist may contact the patient directly if deemed appropriate in the circumstances. In this regard, the patient s telephone number could be captured in the request form details to help that intervention 3.2 Order Communications: GP Order Communications System Electronic Test Ordering and Results Reporting All new GPs seeking access to St. James s Hospital laboratory service must be registered with Healthlink ( ) for both ordering laboratory tests and receiving laboratory reports electronically. Although the system of accessing the communications module may change to a new source agreed between the HSE and General Practitioners in late 2016 and in this case, all Healthlink users will transfer to the new source GPs with existing contracts are required to commit to adopting Healthlink technology within a short timeframe or transfer to any new system agreed between the General Practitioners and the HSE. Note: From a patient safety perspective this is the preferred mode as it eliminates potential errors associated with the manual system (5% error rate reported internationally) thus ensuring the correct results are reported on the correct patient in a timely manner. 3.3 Criteria required for labelling samples The use of printed barcode labels produced by the GP practice management system that are suited to the sample container size is the preferred labelling method as it improves the transfer of accurate clear information All Blood samples i.e. the sample container, must be labelled with a minimum dataset which consists of Patient s Full Name (Surname + Forename) Patient s Date of Birth

3 Page 3 of 6 Note: Barcoded samples will in addition contain the medical registration number of the patient and the tests requested Samples that fail to meet these criteria will be rejected for analysis and will not be processed 3.4 Additional specimen labelling information The following additional information is desirable to have on the specimen, to assist in processing the request and interpreting the results Gender of the patient (this is particularly important where requested investigations have gender-related reference ranges) The date of collection of the specimen (where delayed analysis may lead to erroneous results, this may be required) Time of collection of the specimen. In certain cases, information relating to the timing of specimens is required, for example, in dynamic function testing, to identify peak and trough or pre- and post-treatment specimens or where diurnal variation and circadian rhythms are important for interpreting the result All other (non-blood) samples must, in addition to the above, have the sample type or site, as appropriate, recorded on the sample container (e.g. MSU, Ear Swab) Note: Barcoded samples will in addition contain the medical registration number of the patient and the tests requested For certain clinics where patient s identity is protected e.g. infectious disease clinics, the laboratory will accept samples with the Patient s: Initials + Unique patient identifier DOB Gender Sample site and type ( if not a blood sample) 3.5 Criteria Required for Request Forms The Request Form accompanying the sample/specimen must be legibly written and must include a minimum dataset which consists of: Patient s Full Name Patient s Date of Birth Investigation(s) required Requesting Doctor s name and address or GP Code number Sample type/site recorded on the form (e.g. MSU, Sputum, Ear Swab), if a non blood sample 3.6. Additional request form labelling information The following additional information is desirable to have on the request form, to assist in processing the request and interpreting the results Gender of the patient (this is particularly important where requested investigations have gender-related reference ranges) The date of collection of the specimen (where delayed analysis may lead to erroneous results, this may be required) Time of collection of the specimen. In certain cases, information relating to the timing of specimens is required, for example, in dynamic function testing, to identify peak and trough

4 Page 4 of 6 or pre- and post-treatment specimens or where diurnal variation and circadian rhythms are important for interpreting the result The patient s clinical details should be provided where possible (including any drug or antibiotic therapy) to help in interpretation of results Non-blood samples must, in addition to the above, have the sample type or site, as appropriate, recorded on the request form (e.g. MSU, EAR SWAB) Additional information that might assist with the analysis and reporting should also be included (such as patient s contact telephone number see above) Where available a patient addressograph label and the GP practice stamp should be used on all sheets of the request form as it improves the transfer of accurate clear information For certain clinics where patient s identity is protected e.g. infectious disease clinics, the laboratory will accept samples and request forms with the following information : Patient s Initials, Patient s DOB Unique patient identifier Gender Date sample taken Test examinations clearly indicated Requesting Doctor s name and address or GP Code number GPs using Healthlink must at a minimum provide the first line of the patient s address to avail of the Healthlink messaging system, without which, it cannot be transmitted Certain investigations may require additional information on the specimen or request form. These are detailed in each department s section of the LabMed User Guide at (click on the Lab Services tab in the GPs & Healthcare Professionals section of the site). 3.7 Specimen Transport The packaging used for samples for transport to the laboratory must be in accordance with current Agrement Dangereux Routier (ADR 2016) Safety Legislation and in accordance with SJH laboratory policy available at Laboratory Specimen Transport Policy Advice should be sought from the Laboratory if required The main safety principle of packing and labelling all specimens in such a manner so that they present no threat to those sending, transporting or receiving them must be observed Samples should be sent to the laboratory as quickly as possible after they are obtained in order to avoid sample deterioration which can cause subsequent inaccurate and possibly misleading results In the event an urgent report is required, the User must alert the laboratory by telephone and must ensure it is clearly indicated on the Request Form 3.8 Communication Communication and collaboration between the St. James Hospital and GPs will continue through direct contact and through the St James s Hospital and HSE Management Interface Committee.

5 3.8.2 Additional communication is facilitated through the SJH website, the laboratory GP Newsletter and by direct contact with the laboratory. Page 5 of The Laboratory Manager, Mr John Gibbons, can be contacted at jgibbons@stjames.ie for information. Bibliography 1. Out of Hours Reporting of markedly abnormal laboratory test results to Primary Care: Advice to Pathologists and those that work in Laboratory Medicine. Royal College of Pathologists (UK), ISO (2012): Medical Laboratories-Requirements for Quality and Competence

6 Page 6 of 6 Document Log Document Title Document Number: Document Status i.e. New, Revision, replaced etc General Practitioner Pathology - Laboratory Service Provision Policy SJH: LabMed (P):003 Version Revision Date Description of changes Number Revision 2 January Reference to catchment areas changed 2. Request for GPs to provide emergency contact numbers 3. Criteria for minimum dataset on samples and request forms expanded to include patient initial, DOB and a unique patient identifier Revision 3 January Revised catchment areas 2. Revised scope 3. Revised Healthlink use 4. Revised bibliography Revision 4 4 January 2014 No change Revision 5 5 April Definition changes 2. Standards in section 3 3. updated ADR regulations reference document 4. Revised communication section removed Primary Care contact. 5. Additional desirable information on specimen and request form 6. Updated link to Specimen Transport Policy